AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2692-9562/028
¹Department of Otorhinolaryngology and Audiology, Infermi Hospital, Rimini, Italy.
²Department of Transfusion Medicine and Immunohematology, Infermi Hospital, Rimini, Italy
*Corresponding Author: Enrico Maria Amadei, Department of Otorhinolaryngology and Audiology, Infermi Hospital, Rimini, Italy.
Citation: Enrico M. Amadei, Benedettini L. and Trebbi M. (2021) Infectious Mononucleosis with Upper Airway Obstruction: when tracheotomy and tonsillectomy can be helpful. J. Clin otorhin. 3(2); DOI:10.31579/2692-9562/028
Copyright: © 2021 Enrico Maria Amadei, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 26 February 2021 | Accepted: 05 April 2021 | Published: 08 April 2021
Keywords: infectious mononucleosis; complications; airway obstruction; parapharyngeal abscess; tracheotomy; tonsillectomy
Infectious mononucleosis is caused by Epstein-Barr virus, which infects more than 98% of the world's adult population. Approximately 90% of adults become antibody-positive before the age of 30. The ages of 15-24 years are the most likely time for the onset of symptoms.
We report the case of a 13-year-old girl who came to our emergency department for bilateral erythematous-poltaceous tonsillitis complicated by dysphagia and dyspnea. She had a diagnosis of infectious mononucleosis.
For some hours the young woman presented an inconsistency between a marked respiratory distress and the patency of her upper airways. Finally the clinical picture fell suddenly, requiring an emergency tracheotomy to ensure a patent airway. In the following days a diagnosis of a left parapharyngeal abscess was reached. A tonsillectomy with drainage of the parapharyngeal abscess was required.
It is well known that infectious mononucleosis is typically a silent infection. We describe the case of a girl who risked losing her life due to aggressive infectious mononucleosis, and how we treated her. Such a complicated case has never been described in Literature.
Infectious mononucleosis (IM) is caused by Epstein-Barr virus (EBV), which infects more than 98% of the world's adult population. Approximately 90% of adults become antibody-positive before the age of 30. The age at which primary EBV infection is acquired increases in developed Countries [1]. The incidence in the community of IM is 45/100000, but among adolescents is about 350/100000 [2]. This infection is usually asymptomatic in childhood. The ages of 15-24 years are the most likely time for the onset of symptoms [3]. Patients classically complain fever, fatigue and malaise, lymphadenopathy and odynophagia which resolve within a few weeks.
Complications of IM are numerous but generally rare, such as neurologic, hematologic, cardiac, psychological complications, hepatitis. Some laboratory manifestations are well known [2], such as neutropenia (50-80%), lymphocytosis (more than 4,000 mm³), anemia (3%), thrombocytopenia (25-50%), asymptomatic elevated transaminases (50-80%). Ampicillin rush is also frequent (50-95%), i.e. the erythematous rash on the body, resulting from the intake of beta-lactams in subjects suffering from IM. Interestingly, all doctors are scared of the splenic rupture, which is a rare occurrence (<0>
The purpose of this paper is to present a case of complicated IM, which endangered the life of a young girl, and how we managed this situation. Such a case has never been reported before in Literature.
We present the case of a previously healthy 13-year-old girl who came to our emergency department due to persistent dysphagia and odynophagia for 5 days, despite oral betamethasone 5 mg 2 times a day. She exhibited mild fever (37.2° C), exudative obstructive tonsillar hypertrophy and marked bilateral cervical lymphadenopathy. She had slight dyspnea, without tirage or cornage. Oxygen saturation was 98% in ambient air. The blood tests showed positive IgM against Viral Capsid Antigen (VCA) of EBV ( 160 U/ml), normal white blood cells in number (6.720/mmc), with lymphocytosis (48.5%), Glutamic Pyruvic Transaminase (GPT) was 79 U/L.
Anti-Toxoplasma IgM and IgG were negative, anti-CMV IgG positive and anti-CMV IgM negative, anti-Mycoplasma pneumoniae IgM negative. An otorhinolaryngologist excluded a peritonsillar abscess. Flexible rhinofibroscopy revealed a preserved respiratory space. An ultrasound of the neck revealed marked bilateral lymphadenopathies and excluded signs of colliquation.
After 6 hours the patient presented an increased speech difficulty, with snoring breathing. She had a forced sitting position, even without an increase in respiratory rate (18 breaths per minute). No tirage or cornage, no desaturation. The indication was given for admission to a pediatric ward and intravenous cortisone therapy was initiated (methylprednisolone 1 mg/ kg every 6 hours).
A few hours later the girl suddenly began to desaturate, losing consciousness. An ineffective oral and naso-tracheal intubation required an emergency percutaneous tracheotomy, to stabilize the patient and to ensure effective ventilation. Because of a right pneumothorax she also underwent a thoracotomy.
The following day a surgical tracheotomy was performed (Fig 1). An exudative obstructive hypertrophy of the palatine and lingual tonsils was found, with a diffuse stenosing edema of the oro-hypopharynx. Some biopsies were performed on these anatomical regions for diagnostic purposes, to rule out a lymphoproliferative disease.
Flexible rhinofibroscopy was repeated daily. After 8 days it again revealed a complete upper airways obstruction above the glottic plane, with epiglottic edema and diffuse tonsillar necrosis. Finally a cervical CT showed a left parapharyngeal abscess and a diffuse colliquation of cervical lymph nodes (Figure 2-3).
2 days later a bilateral pericapsular tonsillectomy was performed, with drainage of the abundant purulent collection from the lower pole of the left tonsillar lodge.
After an infectious disease consultation, antibiotic therapy with meropenem plus clindamycin was administered. These were discontinued after the onset of an erythematous skin rash and because of absence of elevated indices of inflammation.
The young woman was transferred from reanimation to the pediatric department after 17 days of hospitalization. She presented the need for tracheal cannula for 1 month, due to the persistence of the upper airway obstruction. She gradually recovered her speaking and swallowing skills. She was released at home after a total of 38 days of hospitalization, with continuation of speech therapy rehabilitation.
Transmission of IM occurs mainly with saliva. Kissing is the major route of transmission of EBV infection among adolescents and young adults, while children transmit IM between each other by exchanging infected toys or contract it by their infected parent. Incubation period of IM is about 6 weeks [1]. Primary infection in childhood is lower in areas with better sanitary conditions. In young adults, the rate of developing IM from primary EBV infection is estimated at 50% [4]-75% [1].
The differential diagnosis should be placed with infections caused by Cytomegalovirus, Toxoplasma gondii, Human Immunodeficiency Virus, Adenovirus, etc. [2].
The simplest and cheapest way to confirm the clinical diagnosis is to search for heterophile antibodies. These are IgM class antibodies, and they are directed against mammalian erythrocytes. This test has a sensitivity of 85% (72% the first week), but it is aspecific and it could be persistent negative in young children. The search for VCA IgM antibody is more expensive, but specific and it has a positivity of 95% (85% the first week). These antibodies become negative 3-12 months post infection [1].
It is well known that IM is typically a silent infection and that vast majority of adult population has antibodies against EBV, without remembering ever being infected [1-2]. This infection is usually asymptomatic in childhood. The ages of 15-24 years are the most likely time for the onset of symptoms [3]. Patients classically complain fever, fatigue and malaise, lymphadenopathy and odynophagia [1-4].
Complications of IM are rare. Asymptomatic elevated transaminases are found in 50-80% of cases, while jaundice is present in 5% of patients [2]. Strangely, well known is the splenic rupture, which is certainly not the most frequent (<0>
Upper airway obstruction (UAO), secondary to IM, is a not rare complication (<5>
About the patient of this paper, two conditions were potentially lethal: an exudative obstructive hypertrophy of the palatine and lingual tonsils, with a diffuse edema of the oro-hypopharynx; and a left parapharyngeal abscess, with persistent airway impairment. Such a complicated case has never been described in Literature until now. UAO is characterized by cornage, tirage, use of accessory respiratory muscles, tachypnea and cyanosis. Desaturation is often late, but unfortunately it is sudden. In a study by Kilham et al. objectivable signs were sought to quantify respiratory distress and predict desaturation. They concluded that eyes of an experienced observer about child’s general appearance were far more valid than any measurable data [9].
Generally UAO post-IM is managed with early intubation of young patients and sometimes with tonsillectomy in Literature. Lots of case reports about tracheotomies performed because of UAO resulting from IM were published between the 40s and 80s of the twentieth century [6-8]. In those years the term mononucleosis was not used, but this disease was known as "anginose type of glandular fever" or as "the kissing disease"[3]. It seems incredible that an emergency tracheotomy was needed in 2021. Yet tracheotomy proved to be, once again, the only quick and safe method to resolve a rapidly evolving UAO, if ineffective intubation.
Some Authors consider tonsillectomy the most effective way to resolve the lasting obstruction [10, 11]. There is no agreement between Authors on surgery, as the risk of postoperative bleeding is high [12]. Lloyd proposed to resort to intracapsular tonsillectomy with microdebridment, with good results [13]. We are not used to perform a tonsillectomy, as long as the acute inflammation persists, because the risk of postoperative bleeding, even if some papers deny this increased risk [14-15]. However, in this case, this procedure was inevitable. It allowed us to resolve a persistent obstruction of the upper airways, caused by the hypertrophy of the tonsillar lymphatic tissue and by a left parapharyngeal abscess.
In symptomatic cases of IM with fever, malaise and pharyngodynia, usually only medicines for fever and pain are used. In Literature there is not uniformity about the use of cortisone for symptom control of IM [3]. This on one hand would reduce inflammation and edema, on the other hand it could prolong the duration of symptoms, also favouring the onset of complications. Some Authors believe that the use of high-dose cortisone (intravenous dexamethasone 0.25 mg/kg or methylprednisolone 1 mg/kg every 6 hours) in case of UAO is indicated and essential [2, 16]. We believe that the use of high-dose cortisone is the only really useful medical therapy in case of UAO.
Although we know that IM is a viral infection, we tried to prevent even greater complications, such as parapharyngeal abscess, due to the appearance of a neutrophilic leukocytosis. Womack et al. recommend using antibiotics only in case of positive rapid test for group A β-haemolytic streptococcus pharyngitis [4]. In this specific case, not only cortisone did not reduce the edema, but even antibiotics did not prevent the abscess. We stopped them at the onset of a widespread skin rash. So in our experience, although we typically use cortisone and antibiotics, both have proved ineffective with our young patient. We do not use antivirals for IM, as there is lack of evidence regarding their effectiveness [2].
We have still many doubts about IM. It is not known why some young people become asymptomatically infected and others develop a severe and potentially fatal disease. It is not know why in some cases autoimmune diseases or malignancies develop following EBV infection. Certainly a vaccine against EBV would be useful, but it is not yet available to date. We hope that the big push in virus vaccination research, such as the recent Sars-Cov2 race, can help prevent future EBV infection and complications.
IM is a very common but often asymptomatic infection. The symptomatic forms are more common among adolescents and young adults. Complications are rare, but not to be forgotten. Upper airway obstruction can be sudden and life-threatening for these patients. Tracheotomy and tonsillectomy are surgical procedures that can solve even the most desperate cases.
Conflict of Interest: None to declare.
Statement of Ethics: The parents gave their informed consent to write this paper.
None to declare.
The parents gave their informed consent to write this paper.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
